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The Stability of Surgically Assisted Rapid Maxillary Expansion (SARME): A

Systematic Review

Dr. Nikhil Gogna, BDS M Clin Dent M. Orth, Specialist Registrar in orthodontics, A.S.
Johal, BDS MSC PHD FDS RCS M. Orth RCS FDS Orth RCS FHEA, Professor /
Honorary consultant in orthodontics, Dr. Pratik k. Sharma, BDS MFDS RCS M. Sc, M.
Orth RCS FDS Orth RCS, Senior clinical lecturer /Honorary consultant in orthodontics

PII: S1010-5182(20)30160-8
DOI: https://doi.org/10.1016/j.jcms.2020.07.003
Reference: YJCMS 3507

To appear in: Journal of Cranio-Maxillo-Facial Surgery

Received Date: 13 April 2020

Revised Date: 3 June 2020
Accepted Date: 5 July 2020

Please cite this article as: Gogna N, Johal AS, Sharma Pk, The Stability of Surgically Assisted Rapid
Maxillary Expansion (SARME): A Systematic Review, Journal of Cranio-Maxillofacial Surgery, https://
doi.org/10.1016/j.jcms.2020.07.003.

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Title

The Stability of Surgically Assisted Rapid Maxillary Expansion (SARME): A

Systematic Review

Authors

Dr. Nikhil Gogna2 (BDS M Clin Dent M. Orth)

Specialist Registrar in orthodontics
drnikhilgogna@hotmail.com

Prof. A.S. Johal1 (BDS MSC PHD FDS RCS M. Orth RCS FDS Orth RCS FHEA)
Professor /Honorary consultant in orthodontics
a.s.johal@qmul.ac.uk

Dr. Pratik k. Sharma1 (BDS MFDS RCS M. Sc, M. Orth RCS FDS Orth RCS)
Senior clinical lecturer /Honorary consultant in orthodontics
p.k.sharma@qmul.ac.uk
(corresponding author)

1. Centre for Oral Bioengineering, Institute of Dentistry, Barts and The London School of
Medicine and Dentistry, Queen Mary University of London, London, UK, E1 2AT

2. Department of Orthodontics. The Royal London Hospital, Whitechapel, London, UK, E1

1BB

Corresponding Author

Dr. Pratik k. Sharma

E-mail: p.k.sharma@qmul.ac.uk
Contact number: +44 (0)20 7882 8805

Centre for Oral Bioengineering

Institute of Dentistry
Barts and The London School of Medicine and Dentistry
Queen Mary University of London
London
E1 2AT
United Kingdom
The Stability of Surgically Assisted Rapid Maxillary Expansion (SARME): A Systematic

Review

ABSTRACT

Background: This systematic review was conducted to determine the stability of surgically

assisted rapid maxillary expansion (SARME) for correction of transverse maxillary deficiency,

the effect of distractor type (tooth-borne vs. bone-borne) and the influence of a retainer on post-

expansion stability.

Methods: The review was conducted applying the PICO criteria. Electronic database searches of

published literature (MEDLINE via PubMed), Ovid via MEDLINE, the Cochrane Oral Health

Group’s Trial Register, Cochrane Central Register of Controlled Trials, LILACS, BBO) and

unpublished literature were accessed until January 2019. Search terms included SARME,

‘stability’, ‘relapse’, ‘surgery’, ‘expansion’ and ‘maxillary expansion’.

Results: Five hundred and ten studies were identified overall and 15 studies were included (3

RCTs, 2 prospective & 10 retrospective) following initial screening and data extraction of full

texts. The quality of evidence was assessed using the Cochrane Risk of Bias tool for RCTs and

the Newcastle-Ottawa Scale for prospective & retrospective studies. The heterogeneity of the

retrieved articles prohibited quantitative analysis. Overall, the studies were either of high risk of
bias or low quality. Qualitative analysis reveals SARPE to achieve expansion at the inter-canine

region of 4-6mm, inter-molar region of 6-8.9mm, and skeletal level of 2.3-3.1mm with relapse

rates in the region of 0.1-2.3mm (inter-canine), 0.2-3mm (inter-molar) and 0-1.8mm (skeletal)

reported.

Conclusion: Qualitative evaluation suggests SARPE results in significant expansion at the

dental and skeletal level and that this appears to be stable. Existing literature is equivocal on the

clinical benefits of a retention device or distractor type (bone-borne vs tooth borne) on stability.

This review has unearthed the need for high quality prospective RCTs to fully understand the

stability of SARME, particularly with relation to varying distractor types and use of retention

devices. As such, the inferences drawn should be considered with some discretion based on the

quality of the available evidence.

Keywords: Stability, relapse, maxillary expansion, surgical expansion

INTRODUCTION

Adequate transverse maxillary dimension is a critical component of a stable and functional

occlusion (Vanarsdall et al., 2005). Transverse maxillary discrepancy and its associated clinical

manifestations play a contributory role in the development of several malocclusions with a

reported prevalence of between 8 to 18% in children (Da Silva Filho et al.,1991; Tausche et

al.,2004).

Various methods of transverse correction are available in growing patients, including dental

expansion and orthopaedic expansion involving the use of rapid maxillary expansion (RME).

However, in non-growing patients, the fusion of the mid-palatal maxillary sutures and increased

skeletal resistance renders RME unsuitable and surgical expansion an ideal choice for correction

(Koudstaal et al., 2009).

Surgically assisted rapid maxillary expansion (SARME) is a ‘procedure in which areas resisting

expansion are surgically released by an osteotomy, and an expander is activated until the desired

amount of expansion is achieved (Betts, 1995). Patients presenting with maxillary deficiency in

the transverse dimension may be treated with SARME resulting in enhancement of the dental

arch space for tooth alignment, producing successful aesthetic and functional outcomes

(Koudstaal et al., 2005).

Applications for the use of SARME have been described in the literature, and the indications

include expansion in a skeletally mature patient, presence of uni - or bilateral cross-bites,

transverse maxillary hypoplasia, crowding, buccal (black) corridors when smiling, unfavourable

inclination of buccal teeth for orthodontic expansion associated with a thin gingival biotype and

where greater than 5mm of expansion is required (Koudstaal et al., 2005; Suri and Taneja, 2008).

Studies assessing transverse surgical expansion have demonstrated poor outcomes in stability

and highlighted the movement as one of the least stable and most problematic surgical

procedures (Profit et al., 2007; Junior et al., 2019). Despite the mounting clinical evidence

pertaining to the use of SARME, research in this field has not been systematically appraised

formerly. This knowledge and evidence base deficit is exemplified by a recent systematic review

aimed at critically appraising all systematic reviews relating to orthognathic surgical stability

which did not include any publications evaluating SARME (Junior et al., 2019).

Therefore, the current systematic review aims to add to the evidence base by evaluating the

stability of surgically assisted rapid maxillary expansion (SARME) for correcting transverse

maxillary deficiency and assessing the influence of distractor type (tooth borne/ bone borne) and

the influence of a retainer (transpalatal arch) on stability.

MATERIALS & METHODS

A comprehensive search strategy was implemented incorporating a variety of databases

including MEDLINE through PubMed (until January 2019), Ovid via MEDLINE (until January

2019), Cochrane Oral Health Group’s Trial Register (until January 2019), Cochrane Central

Register of Controlled Trials (CENTRAL) and non-English databases. Additionally,

unpublished (grey) literature was searched electronically using clinicaltrials.gov, and hand

searching reference lists of included studies was conducted. The systematic review was

performed and described in accordance with the Cochrane Handbook and Preferred Reporting

Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

In keeping with suggested methodology, a population, intervention, comparison and outcome

(PICO) based approach was conducted. The PICO strategy highlighted relevant articles subject

to the following criteria:

1. Population: skeletally mature >16 years old; male and female participants; transverse narrow

maxillary arch; cross-bites, crowding or buccal corridors; non-syndromal.

2. Intervention: the use of SARME.

3. Comparison: SARME vs. control group or SARME vs. alternate treatment.

4. Outcome: the stability of surgically assisted rapid maxillary expansion (SARME), evaluate

the influence of distractor type (tooth borne/ bone borne) on the stability and the influence of a

retainer (transpalatal arch) on stability post- SARME.

Search Strategy

(((((bone-borne) OR ((surgical) OR Surgery))) AND ((maxill* expan*) OR ((((((((SARME) OR

SARPE) OR transvers* expansion) OR transversal expansion) OR transverse expansion) OR jaw

expansion) OR palatal expansion) OR maxillary expansion))) AND (((stability) OR relapse) OR

instability)

Covidence

Prior to study selection, the authors agreed to use a computer programme known as Covidence, a

‘web-based software platform that streamlines the production of systematic reviews.’

The key features of Covidence include an independent process supporting study selection, full

text review, risk of bias (RoB) and data extraction stages and resolution of conflicts and

agreement on final consensus data. Furthermore, the platform allows for storage of full text

reports and allows simple export of data into RevMan or Excel.

Study selection

The database searches were performed by one author (NG) and followed by independent

selection by two authors (NG and PKS). Adherence to the PICO criteria determined the

eligibility of each article and those that fulfilled the pre-requisite criteria were selected for full-

text analysis. Any studies that did not meet the benchmark set were excluded. Additionally, any
potential disagreements between authors about articles were resolved with the input of a third

author (AJ).

Two authors (NG and PKS) independently assessed the articles during the full-text screening

against the PICO criteria with exclusion of studies not meeting the criteria. Data extraction of

the included studies involved the same authors (NG and PKS) independently extracting key

information including demographic data, methodological data, type of distractor, type of surgical

procedure and data on stability outcomes.

Analysis of Surgical Stability

The stability of the surgical procedure was assessed using the mean and standard deviation of the

dental and skeletal changes in the anterior and posterior segments of the maxilla, between the

immediate post-operative period and the last follow-up. All the results were expressed in

millimetres (mm).

Analysis of Methodological Quality

The methodological quality was performed using the Cochrane risk of bias tool for randomised

controlled trials and the Newcastle-Ottawa scale for the selected prospective and retrospective

studies. A multitude of variables were assessed to determine the risk of bias but if all factors

were addressed there would be a low risk of bias.

RESULTS

A PRISMA flowchart (Figure 1) of the systematic review describes the steps leading from the

search strategy to the final included articles. Initial identification retrieved 510 articles, from

which one duplicate study was removed. Consequently, a total of 509 articles were screened

independently by two authors (NG and PKS). From this screening process, 34 articles

progressed onto full text review and 15 studies met the criteria for inclusion in the systematic

review (Pogrel et al., 1992; Stronberg et al.,1995; Northway, 1997; Byloff and Mossaz, 2004;

Antilla et al., 2004; Aloise et al., 2007; De Frietas et al., 2008; Koudstaal et al., 2009; Marchetti

et al., 2009; Sokucu et al., 2009; Seeberger et al., 2010; Gamage and Goss, 2013; Prado et al.,

2014; Habersack et al., 2014; Yao et al., 2015).

The remaining 19 articles were excluded for the following reasons: 5 studies had the wrong

study design (assessed rapid maxillary expansion), 11 studies had the wrong patient population

(age ranges were below age 16 or not specified), 1 study had the wrong intervention, 1 study was

in a foreign language where it was not possible to retrieve an English version and 1 study was a

duplicate publication involving the same cohort of patients.

Description of the Studies

The fifteen studies scrutinised for full text review consisted of three randomised controlled trials
(RCT) (Aloise et al., 2007; Koudstaal et al., 2009; Prado et al., 2014), two prospective (De

Frietas et al., 2008; Yao et al., 2015) and ten retrospective studies (Pogrel et al., 1992; Stronberg

et al.,1995; Northway, 1997; Antilla et al., 2004; Byloff and Mossaz, 2004; Marchetti et al.,

2009; Sokucu et al., 2009; Seeberger et al., 2010; Gamage and Goss, 2013; Habersack et al.,

2014) with publication dates ranging from 1995 – 2016 (Table 1). The randomised controlled

trials assessed either the use of a transpalatal arch vs. no transpalatal arch (Aloise et al., 2007;

Prado et al., 2014) or bone borne vs. tooth borne distractors (Koudstaal et al., 2009). The

prospective studies assessed SARME alone or SARME vs. multi-piece Le Fort I segmental

surgery (De Frietas et al., 2008; Yao et al., 2015). The retrospective studies assessed SARME

alone, SARME vs. RME or SARME vs. 2-part Le Fort I segmental surgery (Pogrel et al.,1992;

Stronberg et al.,1995; Northway, 1997; Antilla et al., 2004; Byloff and Mossaz, 2004; Marchetti

et al., 2009; Sokucu et al., 2009; Seeberger et al., 2010; Gamage and Goss, 2013; Habersack et

al., 2014). All included studies assessed stability.

Analysis of Stability

Table 2 provides an overview of all the studies included outlining the dental and/ or skeletal

changes reported with reference to stability.

Randomised controlled trials

The three RCTs included for review (Aloise et al.; 2007; Koudstaal et al.,2009; Prado et al.,

2014) were all conducted in university hospital based settings originating from two different
countries, namely, Brazil and the Netherlands. The findings were reported in the English

language and published as research articles in three different peer reviewed Journals between

2007 and 2014. They comprised a total sample of 106 subjects including males and females with

a mean age range from 25.8 - 30 years (Table 2).

Two RCTs (Aloise et al., 2007; Prado et al., 2014) aimed to assess the influence of a retention

device on the stability of SARME. In both trials, the retention device of choice was a transpalatal

arch with the intervention group compared against a control group with no retention over a 10-

month period. Prado et al. (2014) found similar expansion rates of the inter-molar width in the

‘retention’ and ‘no retention’ groups of 8.9 & 8.3mm respectively (Table 2). Aloise et al. (2007)

did not account for the amount of expansion achieved but reported a mean inter-molar width

increase of 0.3mm in the retention group and decrease of 1.5mm in the non-retention group. In

comparison, Prado et al. (2014) reported mean inter-molar width reduction of 0.58mm in the

retention group and 1.5mm in the non-retention group at the end of the follow-up period. Both

studies concluded no statistical difference between retention and non-retention groups with

respect to stability following SARME.

A third RCT (Koudstaal et al., 2009) aimed to assess the influence of distractor design on the

stability of SARME comparing tooth-borne distractors against bone-borne distractors. The mean

inter-molar expansion rates reported were 6.8mm and 5.2mm in the tooth-borne and bone-borne

groups respectively. At 12 months, the mean inter-molar relapse in the tooth-borne and bone-

borne groups was 0.5mm and 0.6mm respectively. Furthermore, inter-canine and skeletal
expansion and subsequent relapse was found to be similar in both groups (Table 2), leading the

authors to conclude that there is no difference in stability after SARME when comparing tooth-

borne and bone-borne devices.

Prospective studies

Two prospective studies (De Frietas et al., 2008; Yao et al., 2015) reported on the stability of

SARME over a 12-month follow-up period. Taken together, the aforementioned studies

encompassed a total sample size of 33 patients with a mean age range of 19.2 and 24.5 years

respectively. One study (De Freitas et al., 2008) presented mean expansion figures of 7.2mm and

8.1mm in the inter-canine and inter-molar regions respectively, with corresponding relapse rates

of 1.7mm and 1.5mm at the final follow-up. On a similar note, Yao et al. (2015) described mean

inter-canine and inter-molar expansion values of 5.3mm and 10.0mm respectively. Mean dental

relapse at the 6-month follow-up was reported as being 0.6mm in the inter-canine region and

1.7mm in the inter-molar region. This study also presented data on mean skeletal expansion

reported as 2.3mm in the anterior maxilla and 0.5mm in the posterior maxilla. Furthermore,

skeletal relapse was reported as 0.7mm in the anterior maxilla.

Retrospective studies

Ten retrospective studies reported on the stability of SARME with a total sample size of 204

patients (Table 1). The studies were published as journal articles between 1992 and 2016 and

included subjects with a mean age ranging from 18.5 years to 36.3 years (Table 1). A summary
of the findings of each study in relation to dental and / or skeletal expansion and relapse is

provided (Table 2). Overall, mean expansion rates varied from 3-8.5mm in the inter-canine

region and 3.1-8.7mm in the inter-molar region across the studies. In terms of relapse, the

reported changes across the inter-canine region varied from 0.1-2.5mm and across the inter-

molar region by 0-3mm. Among the studies, skeletal expansion was reported as varying from

1.3-6.9mm with relapse ranging from 0-1.65mm at the final follow up.

Risk of Bias: Cochrane Risk of Bias tool

The Cochrane Risk of Bias tool was applied to the three randomised controlled trials with the

following parameters assessed and reported: random sequence generation, allocation

concealment, blinding participant & personnel, blinding assessor, free from incomplete outcome

data, free from selective reporting and free from other bias. (Table 3 & Table 4).

Overall Quality

In each study, there were two or more categories which were either unclear and/or high risk of

bias. In summary, all 3 RCTs were judged to be of poor quality overall and therefore not

subjected to a meta-analysis (Table 3 & Table 4).

Risk of Bias: Newcastle Ottawa Scale

The Newcastle-Ottawa Scale was applied to the prospective and retrospective studies. The
selection, comparability and outcome were assessed, followed by an overall quality rating with

seven or more points deeming a study to be of good quality. Overall, the retrospective studies

were judged to be of variable quality (Table 5).

DISCUSSION

Transverse skeletal and/ or dental correction is considered a fundamental aim of managing

malocclusions with benefits pertaining to health, function and smile aesthetics widely reported in

the literature (Malandris and Mahoney 2004; Moore et al., 2005; Thilander and Bjerklin, 2011).

Unsurprisingly, therefore, orthopaedic expansion and methods to achieve it have been an area of

interest for many years. The first reported description of the procedure dates back to the middle

of the 19th century (Angell, 1860), and since that time its use as a technique to manage transverse

maxillary deficiency has become a mainstay in contemporary clinical practice.

It is, however, well recognised that orthopaedic expansion has a number of limitations when used

in skeletally mature patients due to closure of the mid-palatal suture, thus hindering the desired

skeletal expansion (Melson, 1975). Furthermore, despite its reported use in adults, a number of

associated problems have been identified which have precluded its widespread application in

mature patients. These have been reported as and include the following: unstable expansion,

tipping of teeth in the buccal segments, fenestration of the buccal cortical bone leading to

gingival recession, damage to periodontium due to compression of the membrane, root resorption

on the buccal surfaces of teeth, unwanted extrusion of teeth, bending of the alveolar bone,
necrosis of the palatal tissue, oral pain and sensitivity (Suri and Taneja, 2008).

As a consequence, SARME is now a widely accepted intervention for correction of transverse

maxillary discrepancies in adults. The technique for surgical widening of the maxillary complex

is popularly regarded to have been first described in 1938 (Brown, 1938). Since that time, novel

advancements in surgical technique in conjunction with development of modern appliances (both

tooth and bone borne) has led to improvements in its application. Despite this, the use of any

surgical intervention must be based on a sound evidence base, particularly in relation to stability.

Limited systematic reviews pertaining to this technique are available and there is, therefore, a

need to critically and systematically appraise the available literature pertaining to the stability of

SARME. At the time of writing, to the best available knowledge of the authors, this is the first

systematic review exploring the stability of SARME.

The aim of the current systematic review was to evaluate the evidence base in relation to the

stability of SARME for correction of transverse maxillary deficiency. Further aims included

evaluation to ascertain if a particular distractor type (tooth borne / bone borne) or use of a

retention device post SARME has an influence on stability. This systematic review included an

overall sample of 343 patients from fifteen different publications. Overall, based on the

Cochrane risk of Bias Tool the RCTs (Aloise et al., 2007; Koudstaal et al., 2009; Prado et al.,

2014) were deemed to be of poor quality (Table 4). Heterogeneity of the selected papers

particularly in relation to outcome assessment of our PICO criteria resulted in meta-analysis of

combined data not being possible. From the remaining studies (Table 5), five were graded as
being of good quality (Northway, 1997; De Frietas et al., 2008; Sokucu et al., 2009; Habersack et

al., 2014; Yao et al., 2015), one graded as fair (Marchetti et al., 2009), with the remaining six

considered to be of poor quality (Byloff and Mossaz, 2004; Antilla et al., 2004; Seeberger et al.,

2010; Gamage and Goss, 2013; Yao et al., 2015). The data was therefore evaluated qualitatively

with the key findings pertaining to stability summarised below.

When assessing the inter-canine width, the vast majority of the studies found a mean expansion

of between 4-7mm (Northway, 1997; Antilla et al., 2004; De Frietas et al., 2008; Koudstaal et

al., 2009; Marchetti et al., 2009, Gamage and Goss, 2013; Habersack et al., 2014). With respect

to the stability of the inter-canine width, there were promising results which were regarded as

stable across all studies, with the majority reporting relapse in the range of 0.1-2.3mm

(Northway, 1997; Antilla et al., 2004; De Frietas et al., 2008; Marchetti et al., 2009; Koudstaal et

al., 2009; Gamage and Goss, 2013; Habersack et al., 2014). The expansion in the inter-molar

width was greater than in the inter-canine region in all studies with the majority reporting values

on the order of 6-8.9mm (Northway, 1997; Koudstaal et al., 2009; Prado et al., 2014). The

relapse rate for the inter-molar width ranged from 0.23-3mm (Northway, 1997; Aloise et al.,

2007; Koudstaal et al., 2009). There was more variability observed in skeletal expansion,

particularly amongst the retrospective studies, ranging from 1.3-6.9mm (Northway, 1997; Byloff

and Mossaz, 2004; Habersack et al., 2014). However, a more consistent range of expansion was

seen in the RCTs and prospective studies ranging 2.3-3.1mm (Koudstaal et al., 2009; Yao et al.,

2015). Skeletal relapse ranged from 0-1.8mm (Northway, 1997; Byloff and Mossaz, 2004;

Aloise et al., 2007; Koudstaal et al., 2009; Yao et al., 2015; Gamage and Goss, 2013; Habersack

et al., 2014). Overall, based on the aforementioned studies, the reported relapse in the inter-
canine region is on the order of 22%, in the inter-molar region approximately 18%, and at the

skeletal level 19% suggesting a favourable outcome in terms of stability measured at the dental

and skeletal level.

Only one RCT (Koudstaal et al., 2009) compared tooth-borne vs bone-borne appliances with

respect to stability which met our PICO criteria. The authors reported no difference in the use of

either distractor type from a stability viewpoint. A recent systematic review, specifically

evaluating tooth borne and bone borne appliances, reported similar findings with the proposed

benefit of a particular distractor type equivocal in the literature (Blæhr et al., 2019). Furthermore,

the benefit in using a retention device post SARME to prevent relapse is unclear based on the

qualitative evaluation of two RCTs that researched this particular question (Aloise et al., 2007;

Prado et al., 2014).

The findings of our systematic review in relation to our overriding aim concluded the existing

literature to be of poor quality overall. In drawing this conclusion, the strengths and weaknesses

of the methodology employed should be evaluated. The strengths included a thorough and

comprehensive search of the existing literature coupled with universally accepted assessment

tools for evaluating full texts. However, limitations of the current review might be the inclusion

of retrospective studies which are prone to reporting bias. Furthermore, the evaluated literature

suffers from a number of weaknesses and variations in methodological design, randomisation

methods, assessments methods, follow-up periods, blinding assessment, sample size calculations,

error of measurement assessment, and standardisation of described techniques leading to

heterogeneity of the retrieved literature restricting quantitative analysis.

In conclusion, notwithstanding the quality and limitations of the literature, qualitative evaluation

does suggest that SARPE can result in significant expansion at the dental and skeletal level and

that this appears to be stable. Currently, there is a lack of confidence in the available literature on

the clinical benefits of using a retention device to aid stability and whether differences exist

between bone-borne and tooth borne appliances in affording a more stable outcome.

Furthermore, the result of this systematic review has unearthed the need for high quality

prospective RCTs to fully understand the stability of SARME, particularly with reference to

varying distractor types and use of retention devices.

Figure 1. PRISMA diagram of the flowchart
Table 1: An overview of studies included for full text review describing the study design,

participant details, intervention and outcomes

Study Method Participants Intervention Outcome

Aloise et al. RCT Sample size: 30; Group 1: Stability- No
(2007) Mean age: 27.3; Retention (TPA); statistical
Male:16 Group 2: No difference
Female:14 retention
Koudstaal et al. RCT Sample size: 46; Group 1: Bone Stability &
(2009) Mean age:30; Borne; Group 2: relapse - No
Male: 23 Female: Tooth Borne statistical
23 difference
Prado et al. RCT Sample size:30; Group 1: Relapse - No
(2014) Mean age: 25.8; Retention (TPA); statistical
Male: 18 Female: Group 2: No difference
12 retention
Yao et al. Prospective Sample size:13; Group 1: Relapse - Le fort I
(2015) Mean age:19.2; SARME ; Group bodily separation
Male:6 Female:7 2: Multi-piece Le and SARME
Fort I tipping
De Freitas et al. Prospective Sample size:20; SARME Relapse - 23%
(2008) Mean age:24.5; relapse in canines
Male:5 18% molars. 1
Female:15 year follow up
Anttila et al. Retrospective Sample size:20; SARME Stability - Good
(2004) Mean age:30.6; (Subtotal Le Fort long term stability
Male: 6 Female: 1) with this
14 technique
Habersack et al. Retrospective Sample size:24; Group 1: 2-piece; Stability - 2-piece
(2014) Mean age:27; Group 2: 3-piece SARME allows
male: 11 Female: SARME for sufficient
13 expansion
Marchetti et al. Retrospective Sample size:10; Group 1: Stability - Le Fort
(2009) Mean age: 23.5; SARME; Group I bipartition more
Male:4 Female: 6 2 Le Fort I stable over 2 years
bipartition
Seeberger et al. Retrospective Sample size:13; Group 1: Stability - Stable
(2010) Mean age:31; SARME ; Group results with both
Male:5 Female:8 2: 2 piece methods
Maxilla
Stromberg et al. Retrospective Sample size: 20; SARME Relapse - Stable
(1995) Mean age:36.3; long term dental
Male:11 results
Female:9
Northway Retrospective Sample size:43; SARME Relapse -
(2016) Mean age:29.1; indicates stable
Male: 6 Female: maxillary
17 expansion
Byloff & Retrospective Sample Size: 14; SARME Stability -
Mossaz (2004) Mean age:27.2; minimal skeletal
Male:11 expansion with
Female:3 skeletal/dental
relapse
Sokucu (2008) Retrospective Sample size: 27; Group 1: RME ; Relapse/arch
Mean age: 18.5; Group 2: depth/palatal
Male:4 Female:9 SARME height - responses
similar in both
groups
Gamage & Retrospective Sample size: 21; SARME Stability &
Goss (2012) Mean age: 19.2; Relapse -60%
Male: 8 Female: overexpansion
13 needed to
compensate for
relapse
Pogrel (1992) Retrospective Sample size: 12; SARME Relapse - Stable at
Mean age: 23; 1 year
Male: 4 Female:
8
Table 2: An Analysis of each included study documenting the Skeletal and/or Dental expansion with relapse rates
Author Trial Design Mean Dental Expansion in mm (SD) Mean Dental Relapse in mm (SD) Mean (mm) Mean (mm)
Skeletal Skeletal
Expansion Relapse (SD)
(SD)
Inter Canine width Inter-Molar width Inter-Canine Width/ Inter-Molar Width/
(SD) (SD)
Aloise et al., RCT - - - Retention: - Retention:
(2007) 0.3 (3.4) 1.5 (2.8)
No Retention:
1.8 (4.9)
No Retention:
-1.5 (4.6)
Koudstaal et RCT Tooth Borne: Tooth Borne: Tooth Borne: Tooth Borne: Tooth Tooth Borne:
al., (2009) 5.9 (3.6) 6.8 (2.9) -2.2 (3.8) -0.5 (1.8) Borne: -0.5 (0.8)
3.1 (2)
Bone Borne: Bone Borne: Bone Borne: Bone Borne: Bone Borne:
6.0 (3.4) 5.2 (3.4) -1.3 (3.2) -0.6 (1.5) Bone Borne: -0.4 (1.3)
3.1 (2.4)
Prado et al., RCT - Retention: - Retention: - -
(2014) 8.9 (3.9) -0.6 (3.4)

No Retention: No Retention:
8.3 (4.72) -1.5 (4.3)
De Freitas et Prospective 7.2 (3.5) 8.1 (3.1) -1.7mm (not -1.5mm (not - -
al., (2008) available) available)

Ant Maxilla: Ant Maxilla:

2.3 (1.8) -0.7 (0.6)
Yao et al., Prospective 5.3 (2.4) 10 (1.4) -0.6 (0.4) -1.7 (1.8)
(2015) Post Post Maxilla:
Maxilla: 0.8 (0.5)
0.5 (0.2)
Pogrel et al., Retrospectiv - 7.5 (Range 6-10) - 0.9 (0.5) - -
(1992) e

Stromberg et Retrospectiv 4.8 (2.7) 7.1 (2.4) 0.2 (2.1) 1.2 (1.3)
al., (1995) e
Northway et Retrospectiv 4.3 (not available) 5.9 (not available) 0.2 (not available) 0.7 (not available) 3.7 (2.2) 0.2 (0.8)
al., (1997) e

Anttila et al., Retrospectiv 4.1 (Range 1.6-8) 7.2 (Range 2.9-13) 0.5 (not available) 1.3 (not available) - -
(2004) e

Byloff & Retrospectiv 5.2 (2.9) 8.7 (5.9) -1.1 (2.5) -2.9 (4.9) 1.3 (2.9) -0.4 (2.7)
Mossaz e
(2004)

Marchetti et Retrospectiv 8.5 (Range 4.5-10.5) 7 (Range 5-9.5) -2.5 (Range 6 to 1) -3 (Range -3.5 to 3) - -
al., (2009) e

Sokucu et al., Retrospectiv - 3.1 (2.1) - 0.2 (2.6) - -

(2009) e

Seeberger et Retrospectiv - 8.3 (1.7) - 0 - -

al., (2010) e

Gamage & Retrospectiv 3.8 (1.9) 6.2 (2.2) 2.3 (Range 6.8) 2.4 (Range 5.8) 4.3 (1.9) 1.7 (Range 2.1)
Goss (2013) e

Habersack et Retrospectiv 2-Piece: 2-Piece: 2-Piece: 2-Piece: 2-Piece: 2-Piece:

al., (2014) e 5.8 (2.6) 6.5 (2.9) -0.6 (0.6) -0.9 (2.8) 6.9 (3) 0 (0.4)

3-Piece: 3-Piece: 3-Piece: 3-Piece: 3-Piece: 3-Piece:

3 (1.9) 6.3 (2.7) -0.1 (0.9) -0.4 (1) 5.7 (3.1) -0.2 (0.2)
Table 3: Describes the included RCTs and judges them based on the Cochrane Risk of Bias tool
determining the overall quality
Author Random Allocation Blinding Blinding Free Free Free Over
Sequence Concealme Participant assessors from from from all
Generatio nt & incompl selectiv other Quali
n Personnel ete e bias ty
outcome reporti
data ng
Aloise UNCLEA UNCLEAR UNCLEAR UNCLE LOW UNCL LOW POO
(2007) R- Used a – No – Doesn’t AR – No RISK – EAR – RISK – R
randomise description address the descriptio No No No
d system outcome n missing protoco obvious
outcome l bias
data availabl
e
Koudstaal LOW LOW RISK UNCLEAR UNCLE LOW UNCL HIGH POO
(2009) RISK – – Opaque – No AR – No RISK – EAR – RISK – R
Computer sealed description descriptio Discusse No Had
generate envelopes n d protoco participa
randomise exclusion l nt drop
d list criteria availabl out
and drop e (attrition
outs bias)
Prado LOW UNCLEAR UNCLEAR HIGH LOW UNCL LOW POO
(2014) RISK – 10 – No – No RISK – RISK – EAR – RISK – R
patient description description No No No No
blocks in 2 blinding missing protoco obvious
groups outcome l bias
data availabl noted
e
Table 4: An additional table of the RCTs visually depicting High risk, Low risk or Unclear
Table 5: Shows the final results from the prospective and retrospective studies once the

Newcastle-Ottawa Scale guidelines were implemented

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